NAME:	Dr.
PERIOD:	FROM:		TO:
	Reason for travel, e.g. visits, VTS	Mileage start	Mileage finish	Total miles
1st				0
2nd				0
3rd				0
4th				0
5th				0
6th				0
7th				0
8th				0
9th				0
10th				0
11th				0
12th				0
13th				0
14th				0
15th				0
16th				0
17th				0
18th				0
19th				0
20th				0
21st				0
22nd				0
23rd				0
24th				0
25th				0
26th				0
27th				0
28th				0
29th				0
30th				0
31st				0
		TOTAL MILEAGE CLAIMED		0
			Pence per mile	£                0.43
			TOTAL TO PAY	£                  -
Standard rate:	Up to 1000cc	1001 to 1500 cc	Over 1500cc
Up to 3,500 miles	£                        0.34	£             0.43	£                0.53
Thereafter	£                       0.162	£            0.183	£               0.205
			Date
Signed GPR
			Practice Stamp
Confirmed GP Trainer